HospitalInspections.org

Based on document review and interview, the facility failed to include 6 contractors on the facility consolidated contractor listing. Services included: Nursing services, Medical staffing, Pathology, Blood bank, and Dialysis.

Findings include:
1. Review of the facility contract list did not include 6 contractors on the facility consolidated contractor listing. Services included: Nursing service, Medical staffing, Pathology, Blood bank, and Dialysis.

2. In interview on 11-21-2019 at 1300 hours, employee #P1, Chief Operating Officer/Chief Nursing Officer, confirmed all the above information.

Based on document review and interview, the facility failed to provide a follow-up resolution, in writing, in 7 of 10 grievances reviewed.

Finding Include:

1. Review of policy titled: Patient Complaint/grievances and Grievances last reviewed January 2019, In all cases, facility "will provide a written response to each grievance, which will include the following:
results of the grievance process
steps taken on behalf of the patient to investigate
date of completion/resolution (if any)
name of the hospital contact person"


2. Review of Grievance Log from 01/01/19 to 10/30/19, 7 grievances lacked documentation of a follow-up letter. They are:
a. SG - 01/01/19
b. GP - 02/28/19
c. CL - 03/18/19
d. NC - 06/03/19
e. DP - 07/11/19
f. KD - 08/28/19
g. MQ - 09/11/19

3. Interview with P#1 (Chief Nursing Officer/Chief Operating Officer) on 11/18/19 at approximately 1:00 confirmed that 7 grievances mentioned in #2 did not have follow-up letters completed.

Based on document review and interview, the facility failed to document receipt of Advance Directives information in 9 of 23 (Patient's 2, 4, 5, 6, 7, 8, 9, 10 and 13) medical records reviewed.

Findings Include:

1. Review of 9 of 22 (Patient's 2, 4, 5, 6, 7, 8, 9, 10 and 13) medical records indicated lack of documentation of patient receiving Patient Rights for Advance Directives.

2. Interview with P#1 (Chief Nursing Officer/Chief Operating Officer) on 11/21/19 at approximately 1:00 pm agreed there are issues with documentation of patients receiving Advance Directives.

Based on document review and interview, the facility failed to include a monitor and standard for six (6) contract services: Nursing services, Medical staffing, Pathology, Blood bank, and Dialysis as part of the hospital QAPI program.

Findings include:
1. Review of quarterly QAPI reports did not include a monitor and standard for six (6) contract services: Nursing services, Medical staffing, Pathology, Blood bank, and Dialysis.

2. In interview on 11-21-2019 at 1300 hours, employee #P1, Chief Operating Officer/Chief Nursing Officer, confirmed that the 6 contract services listed above were not included in the facility QAPI program.

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Based on document review and interview, 3 of 12 blood transfusions reviewed failed to be administered in accordance with approved medical staff policies and procedures.

Findings included:

1. Review of policy/procedure titled: "Blood, Blood Products, Derivatives Administration," policy number "PCS-18," last reviewed "January 2019" read: "An Informed (sic) consent for "Transfusion or Administration of Blood/Blood Products/Blood Derivatives" must be signed prior to administration..." and "...Verify the following with a second nurse (one must be a RN) at bedside and sign record...Patient Name, Medical record number, Blood type, Expiration Date of Blood Product, Unit #, Blood bank number (Y number), Compatibility (RBC's)..."

2. Review of patient blood transfusion documentation indicated the following:
a. Patient L2 had a physician's order to transfuse one unit of platelets on 8-23-2019. The order indicated the patient signed a consent form for the transfusion. The transfusion was administered on 8-23-2019 from 9:05 PM to 9:30 PM. The patient's medical record did not contain a consent for the transfusion.
b. Patient L11 received a platelet transfusion on 8-22-2019. The "Blood Transfusion Record" did not contain the signature of a second nurse to verify the patient's identification.
c. Patient L12, admitted on 9-23-2019, had a physician's order on 9-24-2019 to transfuse two units of packed red blood cells. The first unit was administered on 9-25-2019 from 6:00 PM to 7:50 PM. The second unit was administered on 9-25-2019 from 8:30 AM to 12:30 AM on 9-26-2019. The patient's medical record contained a "Refusal of Blood and Blood Derivatives" form signed by the patient on 9-24-2019 at 6:15 AM, which read: "Due to my personal or religious beliefs, I...the patient named below...request that no blood or blood derivatives be administered to the patient named below during this inpatient or outpatient encounter..." The patient's medical record did not contain a consent for the transfusion.

3. In interview on 11-21-2019 at 10:22 AM, P4, Charge Nurse confirmed the following:
a. There was no blood transfusion consent for Patient L2.
b. The "Blood Transfusion Record" for Patient L11 did not contain the signature of a second nurse to verify the patient's identification.
c. The "Blood Transfusion Record" should contain the signatures of two different nurses to verify the patient's identification.
d. Patient L13 signed a form to refuse blood administration, but received two units of packed red blood cells on 9-25-2019 and 9-26-2019.
e. There was no blood transfusion consent for Patient L12.

Based on document review and interview, the facility failed to ensure complete documentation in 6 of 41 (P12, L14, L15, L16, L17 and L18) medical records reviewed.

Findings Include:

1. Facility lacked policy requiring completeness of document per P4 (Registered Nurse - Charge) on 11-21 at 12:10 PM.

2. Review of medical records indicated:
a. Patient #12 admitted 11/11/19; heart catheterization on 11/13/19; lack of documentation of a TIME-OUT before the procedure.
b. Patient L14 was admitted on 10-25-2019 at 1:38 AM and discharged on 10-30-2019 at 2:45 PM. The patient's medical record lacked percent (%) meal intake documentation for a bedtime snack on 10-25-2019; dinner on 10-26-2019; bedtime snack on 10-28-2019; and lunch and dinner on 10-29-2019.
c. Patient L15 was admitted on 11-11-2019 at 2:45 PM and discharged on 11-14-2019 at 3:02 PM. The patient's medical record lacked % meal intake documentation for dinner on 11-12-2019.
d. Patient L16 was admitted on 11-1-2019 at 11:37 AM and discharged on 11-5-2019 at 1:18 PM. The patient's medical record lacked % meal intake documentation for dinner on 11-1-2019; bedtime snack on 11-2-2019; dinner and bedtime snack on 11-3-2019; and bedtime snack on 11-4-2019.
e. Patient L17 was admitted on 11-8-2019 at 5:08 PM and discharged on 11-13-2019 at 3:50 PM. The patient's medical record lacked % meal intake documentation for breakfast, lunch, and dinner on 11-10-2019; and breakfast and dinner on 11-12-2019.
f. Patient L18 was admitted on 11-9-2019 at 3:12 PM and discharged on 11-12-2019 at 1:45 PM. The patient's medical record lacked % meal intake documentation for breakfast and lunch on 11-12-2019.

3. Interview on 11-20-2019 at 10:22 am with P4 (Registered Nurse - Charge), acknowledged the missing documentation as documented in number 2.

Based on document review and interview, the facility failed to ensure appropriate authentication of a History and Physical in 2 of 23 (Pt#2 and Pt#13) medical records reviewed.

Findings Include:

1. Review of Medical Staff Rules and Regulations last approved 12/11/18, under Article IV, indicated "Any history and physical examination entries that are not made by a physician must be countersigned by the attending or supervising physician within seven (7) days".

2. Review of Pt#2 (admission date of 8/12/19) and Pt#13's (admission date of 5/16/19) medical records indicated History and Physical completed by a Nurse Practitioner (NP) and lacked documentation of a supervising physician.

3. Interview with P#4 (Registered Nurse Charge) on 11/19/19 at approximately 2:00 pm agreed lack of counter signature on Pt#2 and Pt#13 medical records.

Based on document review and interview, the facility failed to provide a History and Physical in 4 of 23 (Pt#4, Pt#5, Pt#12 and Pt#14) medical records reviewed.

Findings include:

1. Review of the Medical Staff Rules and Regulations last approved 12/11/18, under Article IV, indicated a "History and Physical examination shall be recorded within 30 days before or within 24 hours after an admission".

2. Review of Pt#4, Pt#5, Pt#12 and Pt#14's medical records lacked documentation of a History and Physical.

3. Interview with P#1 (Chief Nursing Officer/Chief Operating Officer) on 11/21/19 at approximately 1:00 pm agreed there are issues with History and Physicals.

Based on document review and interview, the facility failed to ensure 4 of 23 (Pt#2, Pt#3, Pt#4 and Pt#12) medical records, with greater than 48 hour stays, reviewed had a documented Discharge Summary.

Findings Include:

1. Review of Medical Staff Rules and Regulations last approved 12/11/18, indicated under Article IV, "Discharge Summary shall be recorded on all patients hospitalized greater than 48 hours".

2. Review of 4 of 22 (Pt#2, Pt#3, Pt#4 and Pt#12) medical records indicated a lack of documented Discharge Summary.

3. Interview with P#1 (Chief Nursing Officer/Chief Operating Officer) on 11/21/19 at approximately 1:00 pm agreed there are issues with documentation of Discharge Summary.

Based on document review, observation, and interview, the medical staff failed to ensure drug storage was in accordance with accepted professional principles in two instances.

Findings included:

1. Review of manufacturer's package insert for "Isovue-300 and Isovue-370," revised March, 2017, read: "Store at 20-25°C (68-77°F)."

2. Review of manufacturer's instructions for "Barium E-Z-HD" and "Barium E-Z Paque," last updated 9-30-2019, read: "Store at 20°C to 25°C (68°F to 77°F)."

3. Review of policies/procedures indicated the following:
a. A policy/procedure titled: "Contrast Media Storage and Distribution," policy number "RD-6," last reviewed "January 2019," read: "Contrast media is stored and distributed according to the manufacturer's recommendations."
b. A policy/procedure titled: "Contrast Media Warmer," policy number "RD-102," last reviewed "January 2019," read: "...To maintain the constant required temperature of the contrast media..." and "Temperature is to be between 35 C and 40 C inside the warmer..."

4. Review of "Radiology Contrast Warmer Temperature Log" for September 2019, October 2019, and November 2019, read: "Vials may be stored in warmer for up to 30 days..." and indicated the "ideal" temperature was 37°F (Fahrenheit), not 20-25° C (Celsius). The logs indicated the warmer temperature was 37° F during September, 2019, October, 2019, and November, 2019.

5. During tour of the radiology department on 11-20-2019 at 1:13 PM, while accompanied by P5, Respiratory Therapist Lead, the following was observed:
a. Two 100 milliliter (mL) bottles of "Isovue-370" contrast media, lot number ADP9563A, expiration date June, 2022, were observed to be stored in the contrast warmer in the Computed Tomography (CT) room.
b. One 100 Ml bottle of "Isovue-370" contrast media, lot number ADP9555A, expiration date February, 2022, was observed to be stored in the contrast warmer in the CT room.
c. The temperature reading on the contrast warmer in the CT room read 32.1°C.
d. Eleven vials of "Isovue-300" contrast media were observed to be stored in the clean utility room.
e. Thirteen vials of "Isovue-200" contrast media were observed to be stored in the clean utility room.
f. Eighteen bottles of "Liquid EX Paque" Barium sulfate were observed to be stored in the clean utility room.
g. Thirteen bottles of "EZ HD" Barium sulfate were observed to be stored in the clean utility room.
h. Thirty bottles of "Isovue 370" were observed to be stored in the clean utility room.
i. There was no thermometer or temperature log observed in the clean utility room.

6. On 11-20-2019 at 2:42 PM, P10, CT Technician, confirmed contrast media is stored in the contrast warmer for up to 30 days.

7. On 11-20-2019 at 3:19 PM, P1, Chief Nursing Officer/Chief Operating Officer, indicated the temperature of the entire hospital is set between 68°F and 76°F and an alarm would be activated if the temperature exceeds that range. P1 further acknowledged there is no thermometer in the clean utility room nor is there a log to document the temperature of the clean utility room where the contrast media and barium were stored. P1 was unsure if the temperature alarm for the hospital would be activated if the temperature in the clean utility room where the contrast media and barium were stored exceeded the temperature range of 68°F to 76 °F.

7. Review of patient records indicated the following patients received a CT scan with contrast as follows:
a. Patient L19, date of service: 11-15-2019.
b. Patient L20, date of service: 11-19-2019.
c. Patient L21, date of service: 11-18-2019.

Based on document review and interview, patient diets failed to be ordered by a practitioner for 3 of 6 patient dietary records reviewed.

Findings included:

1. Review of patient dietary records indicated the following:
a. Patient L13 was admitted on 11-11-2019 at 7:08 AM and discharged on 11-12-2019 at 2:15 PM. A physician diet order on 11-11-2019 at 10:00 PM read: "Clear Liquids - progress to regular as tolerated." The "12-hour Intake and Output Record" for 11-11-2019 and 11-12-2019 indicated the patient received a "heart healthy" diet instead of the regular diet ordered by the physician.
b. Patient L14 was admitted on 10-25-2019 at 1:38 AM and discharged on 10-30-2019 at 2:45 PM. A physician diet order on 10-28-2019 at 1:05 PM read: "Clear Liquids - progress to regular as tolerated." The "12-hour Intake and Output Record" for 10-29-2019 and 10-30-2019 indicated the patient received a 2000 calorie diabetic diet on those dates, instead of the regular diet ordered by the physician.
c. Patient L16 was admitted on 11-1-2019 at 11:37 AM and discharged on 11-5-2019 at 1:18 PM. There were no diet orders upon admission. A physician diet order on 11-2-2019 read: "NPO after breakfast 11-4-2019" (nothing by mouth). There were no other diet orders in the patient's medical record. The "12-hour Intake and Output Record" for 11-1-2019, 11-2-2019, 11-3-2019, and 11-5-2019 indicated the patient received an 1800 calorie diabetic diet on those dates.

2. In interview on 11-21-2019 at 10:22 AM, P4, Charge Nurse, confirmed the following:
a. Patient L13 did not have an order for a heart healthy diet, but received a heart healthy diet.
b. Patient L14 did not have an order for a 2000 calorie diabetic diet on 10-29-2019 and 10-30-2019, but received a 2000 calorie diabetic diet on those dates.
c. The only diet order for Patient L16 was "NPO after breakfast 11-4-2019," but the patient received an 1800 calorie diabetic diet on 11-1-2019, 11-2-2019, 11-3-2019, and 11-5-2019

Based on document review and interview, the dietician failed to approve the current therapeutic diet manual for 2019.

Findings included:

1. Review of the approval document for the therapeutic diet manual indicated P11, the facility's former dietician, approved the "Indiana Diet Manual 9th Edition" and the "Nutrition Care Manual" on 3-13-2018.

2. Review of the "Nutrition Care Manual" indicated the manual is updated annually in October.

3. In interview on 11-19-2019, P1, Chief Operations Officer/Chief Nursing Officer, indicated the separation date for P11 was 4-12-2019.

4. In interview on 11-20-2019 at 1:58 PM, P7, Registered Dietician, acknowledged the "Indiana Diet Manual 9th Edition" and the "Nutrition Care Manual" were both approved on 3-13-2018 by a former dietician, P11, who was no longer employed at the facility. On the same date at 2:20 PM, P7 further confirmed they had not yet approved a therapeutic diet manual, nor did they know how often the therapeutic diet manual was to be approved. On the same date at 2:49 PM, P7 acknowledged the "Nutrition Care Manual" was updated annually and indicated their hire date was 5-7-2019.

Based on record review, observation and interview; the facility failed to ensure 3 of 7 means of egress were continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency, failed to ensure 1 of 1 electrical equipment room door was only held open by a release device complying with LSC 7.2.1.8.2 that automatically closes such doors upon activation of the fire alarm system, failed to ensure materials used as an interior finish in the lobby and on the walls of 3 of 3 Data Rooms had a flame spread rating of Class A or Class B in accordance with 19.3.3, .failed to ensure the penetrations caused by the passage of wire and/or conduit through 2 of 2 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier (see tag 710), failed to provide a complete facility specific written fire safety plan for the protection of 18 of 18 patients to accurately address all life safety systems, plus a system addressing all items required by NFPA 101, 2012 edition, Section 19.7.2.2. (see tag 714) and failed to provide evidence of scheduled periodic maintenance for one (1) patient physical therapy step apparatus, failed to document sprinkler system inspections in accordance with NFPA 25, failed to ensure 19 of 68 fire door assemblies were maintained in accordance of LSC 19.1.1.4.1.failed to maintain 1 of 1 piped gas system in accordance with NFPA Health Care Facilities Code requirement at Section 99 5.1.14.4.8 (see tag 724).


The cumulative effect of these systemic problems resulted in the facility's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on record review, observation and interview; the facility failed to ensure 3 of 7 means of egress were continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency, failed to ensure 1 of 1 electrical equipment room door was only held open by a release device complying with LSC 7.2.1.8.2 that automatically closes such doors upon activation of the fire alarm system, failed to ensure materials used as an interior finish in the lobby and on the walls of 3 of 3 Data Rooms had a flame spread rating of Class A or Class B in accordance with 19.3.3.1. LSC 10.2.3.4 states products required to be tested in accordance with ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale. This deficient practice could affect all building occupants, failed to protect 1 of 1 Fire Pump Room in accordance with NFPA 20, Standard for the Installation of Stationary Pumps for Fire Protection (2010). Section
4.12.2.1 states that access to the fire pump room shall be pre-planned with the fire department and Section 4.12.2.1.1 states that Fire pump rooms not directly accessible from the outside shall be accessible through an enclosed passageway from an enclosed stairway or exterior exit. The enclosed passageway shall have a minimum 2-hour fire-resistance rating, failed to ensure the penetrations caused by the passage of wire and/or conduit through 2 of 2 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8.5. 8.5.6.3 states that where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5. 8.3.5.1 states that penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The fire stop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops. .


1. During a tour of the facility with the Chief Operations Officer on 11/20/19 from 9:00 a.m. to 12:00 p.m. the following conditions were found:
a) At 9:30 a.m. the two West exit doors from the PACU did not open without excessive force. Based on interview at the time of observation, the Chief Operations Officer did not know when or how often the doors are exercised to ensure reliable operation. Additionally, she agreed that the doors would impede evacuation from the PACU.
b) At 9:57 a.m. the exit door from the sterile processing room was blocked by a cart of surgical implements. Based on interview at the time of observation, the Chief Operations Officer agreed that the cart obstructed the means of egress.

2. During a tour of the facility with the Chief Operations Officer on 11/20/19 at 10:40 a.m. the door to the Automatic Transfer Switch room which was in a Fire Barrier with a 1-hour Fire Resistance Rating, was found propped open with a metal wedge. Based on interview at the time of observation, the Chief Operations Officer confirmed the wedge hold open device did not release with the fire alarm.

3. During a facility tour with the Chief Operations Officer on 11/20/19 between 9:00 a.m. and 12:00 p.m. the lobby was found to have wood paneling on the walls. Based on interview, the Chief Operations Officer stated she could not provide documentation regarding the flame spread of the paneling. Additionally, she stated that the paneling had previously been treated with flame retardant, however could not provide documentation regarding the type, or the date of application. Then, three data rooms were found to have oriented strand board (OSB) on the walls behind the telecommunications equipment. The wood had been painted over. Based on interview at the time of observation, the Chief Operations Officer stated that she could not provide documentation regarding the flame spread of the oriented strand board.

4. During a tour of the facility with the Chief Operations Officer on 11/20/19 at 10:25 a.m. it was found that the Fire Pump Room was located in an isolated room protected by a Fire Wall with a 2-Hour Fire Resistance Rating. However, the Pump Room was not accessible from the outside, and was not accessible through an enclosed passageway from an enclosed stairway or exterior exit. Entry to the Fire Pump Room was only possible through a Supply Room with combustible storage. Based on interview at the time of observation, the Chief Operations Officer confirmed the supply room was the only access to the Fire Pump Room.

5. Based on observations with the Chief Operations Officer on 11/20/19 between 11:18 a.m. and 12:00 p.m. the following penetrations were found:
a) At 11:18 a.m. a 1 X 2 inch unsealed penetration was found between drywall above the lay-in ceiling near the east post-anesthesia care unit southeast door.
b) At 11:21 a.m. an unsealed penetration in a 2-inch stubbed out conduit was found above the lay-in ceiling tile in the corridor south east of the post-anesthesia care unit.
c) At 11:25 a.m. an unsealed penetration in a 1-inch stubbed out conduit was found above the lay-in ceiling tile in the corridor northeast of the Operating Room doors.
d) At 11:27 a.m. 2 unsealed penetration in 1-inch stubbed out conduits was found above the lay-in ceiling tile near the staff lounge.
e) At 11:33 a.m. a 3 x 12 inch unsealed penetration was found above the Sterile Processing room rolling fire door where drywall had been removed.
f) At 11:38 a.m. an unsealed penetration in a 2-inch stubbed out conduit was found above the lay-in ceiling tile near the hospitality room; a 1 x 6 inch unsealed penetration was found above the lay-in ceiling tile where drywall had been removed around a conduit near the hospitality room; a 1 x 1 inch unsealed penetration around a structural 'L' bracing above the lay-in ceiling tile near the hospitality room.
g) At 11:53 a.m. an unsealed penetration in a 2-inch stubbed out conduit was found above the lay-in ceiling tile near the inpatient hospitality room. Based on interview at the time of observations, the Chief Operations Officer confirmed penetrations were in the smoke barriers and agreed with the measurements. It was noted that findings a through e were corrected prior to the facility exit on the same date.

Based on record review, observation, and interview, the facility failed to provide a complete facility specific written fire safety plan for the protection of 18 of 18 patients to accurately address all life safety systems, plus a system addressing all items required by NFPA 101, 2012 edition, Section 19.7.2.2. LSC 4.8.2.1(3) requires evacuation procedures appropriate to the building, its occupancy, emergencies and hazards. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
This deficient practice could affect all occupants in the event of an emergency.

Findings include:

Based on a review of the fire plan 11/19/19 at 10:40 a.m. with the Chief Operations Officer present, the deficiencies were identified:
a) The fire plan did not address the use of alarms or transmission of alarm to the fire department.
b) The fire plan did not identify smoke compartment doors completely. Based on observation, the facility had cross-corridor doors that were not in smoke compartment barriers. During interview at time of observation, a facility nurse with two years employment, mis-identified which cross-corridor doors would complete smoke compartment evacuation and stated she was not trained on which doors were part of smoke barriers and would offer protection.
c)The fire plan did not address the preparation of floors and building for evacuation. The plan states that access to all exits are free and unobstructed. During the subsequent tour, a portable x-ray machine was located in a means of egress.
Based on interview at the time of record review and observation, the Chief Operations Officer agreed that the fire plan was not complete.

Based on document review and interview, it could not be determined if the facility conducted scheduled periodic maintenance for one (1) patient physical therapy step apparatus, failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request, failed to ensure 19 of 68 fire door assemblies were maintained in accordance of LSC 19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly and failed to maintain 1 of 1 piped gas system in accordance with NFPA Health Care Facilities Code requirement at Section 99 5.1.14.4.8 which states that audible and visual alarm indicators shall meet the following requirements:
(1) Tested periodically to determine that they are functioning properly
(2) Records of the test shall be maintained until the next test is performed.

Findings include:
1. On 11-20-2019 at 1400 hours, it was observed that the physical therapy step apparatus was not listed on the facility's periodic equipment maintenance schedule.

2. In interview on 11-21-2019 at 1300 hours, employee #P1, Chief Operating Officer/Chief Nursing Officer, confirmed that there was no available maintenance documentation for the facility physical therapy step apparatus.

3. Based on review of the fire sprinkler vendor documentation for the most recent twelve month period with the Chief Operations Officer during record review from 10:00 a.m. to 2:15 p.m. on 11/19/19 the following was found:
a) Monthly wet sprinkler system gauge inspection documentation for 10 months of the most recent 12 month period was not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 10 months of the most recent 12 month period was not available for review.
b) Gauge and valve inspection documentation was not itemized for 2 of 2 months. Based on record review, the facility had four sprinkler zones. Documentation stated "Gauges: Passed and Valves: Passed" Based on interview at the time of record review, the Chief Operations Officer agreed that the documentation for 10 of the most recent 12 months was not available, as it was not recorded, and agreed that documentation for the most recent 2 months, which were recorded, was not itemized.

4. Based on observation and interview, the facility failed to ensure the spray pattern for sprinklers were not obstructed in 1 of 1 storage rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, as required by LSC 19.3.5.1. NFPA 25 Section 5.2.1.2 states the minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors. Section 5.2.1.3 states stock, furnishings, or equipment closer to the sprinkler deflector than permitted by the clearance rules of the installation standard shall be corrected. NFPA 13, 2011 edition, Section 8.5.5.1 states sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2 and 8.5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Sections 8.5.5.2 and 8.5.5.3 do not permit continuous or noncontinuous obstructions less than or equal to 18 inches below the sprinkler deflector or in a horizontal plane less than 18 inches below the sprinkler deflector that prevent the spray pattern from fully developing. This deficient practice could affect staff only.

5. During a facility tour with the Chief Operations Officer on 11/20/19 at 9:35 a.m. storage was found within 18 inches of a sprinkler in the Radiology storage room. The storage was measured to be 18 inches from the base of the concealed sprinkler cover plate. Based on interview at the time of observation, the Chief Operations Officer stated that the sprinkler, when activated, drops 1.5 inches, resulting in only 16.5 inches to the obstruction. This was confirmed by the Chief Operations Officer, who agreed with the measurement, at the time of observation.

6. Based on observation and interview, the facility failed to maintain the ceiling construction in one area throughout the facility. The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect all staff and visitors in the kitchen.

7. During a tour of the facility with the Chief Operations Officer on 11/20/19 at 9:46 a.m. a 4 inch by 4 inch penetration was found in the suspended ceiling lay-in panels around conduits in the kitchen. This was confirmed by the Chief Operations Officer at the time of observation.

8. NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all occupants.

9. During record review with the Chief Operations Officer on 11/19/19 at 12:16 p.m., vendor provided documentation indicated that during the annual inspection of the fire door assemblies on 10/16/19, 19 of 68 doors were found to be non-compliant. Based on interview at the time of record review, the Chief Operations Officer stated they had provided the inspection results to the facility door vendor for solutions, however was unable to provide any additional documentation regarding quotes or provided solutions.

10. During a facility tour with the Chief Operations Officer on 11/20/19 at 9:33 a.m. when requested, the Chief Operations Officer and staff nurses were unable to test the remote alarm panel of the piped medical gas systems and were not aware that the panel could be tested. Additionally, the Chief Operations Officer stated that the testing of the remote alarm panels should be conducted during monthly Periodic Maintenance. During document review the previous day, 11/19/19, the only documentation provided regarding testing or maintenance of piped medical gases was the annual test and inspection dated 07/02/19.

Based on observation and interview, the infection control officer failed to develop policies in regard to replenishment of hand sanitizer in one instance.

Findings included:

1. During a tour of the laboratory on 11-18-2019 at 10:21 AM, while accompanied by P5, Respiratory Therapist Lead, and P6, Phlebotomist, a 400 milliliter (mL) bottle of "Deb InstantFOAM" hand sanitizer was observed on the phlebotomy cart. The manufacturer printed lot number and expiration date on the bottle were illegible.

2. During a tour of the laboratory on 11-20-2019 at 1:42 PM, the same bottle of "Deb InstantFOAM" hand sanitizer was observed on the phlebotomy cart with the manufacturer printed expiration date and lot number illegible. A sticker with the handwritten expiration date of "2/2020" was affixed to the front of the bottle.

3. In interview on 11-18-2019 at 10:26 AM, P6 indicated the bottle of "Deb InstantFOAM" hand sanitizer observed on the phlebotomy cart was rinsed out with warm water, allowed to air dry, then refilled with "Purell Advance Hand Sanitizer Foam" when the bottle was empty.

4. In interview on 11-19-2019 at 2:19 PM, P8, Infection Control Nurse, confirmed hand sanitizer bottles should not be topped off or refilled. P8 further indicated there was no policy/procedure regarding refilling hand sanitizer bottles.

Based on observation and interview, the facility failed to provide a sanitary environment in 3 areas of the facility -- Radiology, Pre/Post-Operative and Medical/Surgical area.

Findings Include:

1. Facility lacks policy detailing high/low dusting per P#1 (Chief Nursing Officer/Chief Operating Officer) on 11/21/19 at 1:00 pm.

2. Tour of facility on 11/18/19 with P#4 (Registered Nurse -- Charge) surveyor observed and P#4 confirmed:
a. Medical/Surgical Unit at 10:00 am; copious, visible and wipeable dust observed on top of crash cart and visible and wipeable dust on top of the ice/water machine.
b. Pre/Post-Operative Unit at 11:40 am; visible and wipeable dust observed on top of refrigerator and copious, visible and wipeable dust on top of medication tower.

3. Tour of facility on 11/20/19 at 1:28 pm with P#5 (Respiratory Therapist Lead); surveyor observed and P#5 confirmed: visible and wipeable dust on the top ledge of the restroom mirror of the x-ray room.